Abdulla AlSubai

Disease Symptoms Management

Hypertension ● Both EHT and Secondary HTN affect individuals above 40 Diagnosis
● Cardiac - Chest pain, Dyspnea ● 24-Hour BP Reading
● Cardiac and renal failure - peripheral oedema ● FBC and Blood-testing - indicates fasting lipid panel,
● Neural - Headaches, confusion, weakness glucose levels, U&E
● Ocular - visual impairment ● Fundoscopy - especially if Diabetic (Hypertensive
Retinopathy)
Secondary HTN - ● ECG - indicating left ventricular hypertrophy
1. Above 40 yrs
2. Severe HTN (> 180/110mmHg) Treatment
3. Refractory (uncontrollable) HTN ● First-line management is non-pharmacological
4. Presence symptoms of Cushing’s or other risk factors

Adrenal-induced ● Pheochromocytoma - episodic headaches, tachycardia /

Hypertension palpitations, sweating, paroxysmal hypertension

Coronary Artery Stable Angina and Acute Coronary Syndromes (Unstable Angina)
Diseases 1. Crushing, central, dull chest pain
- Exercise-induced is Stable Angina, with no change in
symptoms over weeks
- At rest is Unstable Angina (for greater than 20 minutes -
either presents as a new onset of severe angina, or
increases in frequency with reduced effort and increased
severity)
2. Chest pain radiates down arm, neck, jaw
3. Pale or flushed
4. Dyspnea and weakness
5. Sweating, or cool and clammy
6. Nausea and vomiting
7. Anxiety - sense of impending doom, fear of death, timor mortis

Acute Myocardial Similar characteristics to the above - with exceptional features, i.e 1. ECG - GOLDEN STANDARD
Infarction - STEMI/NSTEMI and Troponin 2. Cardiac Enzymes
- Heart attack and leads to sudden death or collapsing, don’t 3. If requiring stenting - conduct a CT Coronary
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forget that !!!! - more severe symptoms than ANGINA Angiography

- Acute condition (never seen like it before) that is worsened
from the patient’s baseline of effort or tolerance to exercise -
pain is made worse with exercise (but not induced by the
exercise itself)
- Does not relieve through rest or NTG spray
- Severe pain radiating to the jaw, left arm, and down.
- Severe crushing chest pain - clenching their fists (Levine Sign)
- Very constricting chest discomfort, tightness, sense of squeezing
pressure

Uncommon symptoms
- For diabetics, women, older patients - can be a silent MI
- Chest pain associated with upper abdominal pain, nausea,
and other GI symptoms
- GIT symptoms indicate an inferior infarct
- Other uncommon symptoms are presyncope, syncope,
weakness and dyspnea, fatigue, palpitations, PND /
orthopnea

Cardiogenic shock Hypotension

(Systemic Tachycardia
Hypotension) Weak thready pulse
Cool, clammy skin - looks sweaty but is very cold
Impaired cognition
Pale, ashen skin

Pathology of Chronic ● Enlarged and dilated heart - Primary prevention is key

Ischaemic Heart ● Dilated AV ring - Diagnosed through angiography (non-invasive coronary
Disease ● Mitral valve incompetence - backflow of systolic blood into LA imaging)
- Heart failure drugs, i.e. ACE-inhibitors
- Statins and angioplasty

Pulmonary Oedema ● Heavy, wet lungs

● PAROXYSMAL NOCTURNAL DYSPNEA (PND) / SOB
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Signs of Vascular ● Carotid bruit - systolic murmur of carotids on auscultation

Diseases (inclusive of ● Amaurosis fugax - impaired visual fields
MI) ● Extensive abdominal aorta - due to Aneurysms
● Abnormal peripheral pulses (dorsalis pedis, popliteal, etc)

Aortic Dissection Ripping-like chest pain that radiates from the chest, towards the back

Pericarditis 1. Flu-like symptoms Diagnosis

2. Chest pain relieved on leaning forward 1. ECG - GOLD STANDARD
3. Widespread wedge-shaped ST elevation or depression 2. Culturing Pericardial fluid via Pericardiocentesis
4. Pericardial friction rub (due to Pericardial effusion) (uncommon)

Treatment
● Restrict physical activity
● Provide NSAIDs and Colchicine / Steroids
● Drain pericardial effusion (if large)

Arrhythmias Symptoms /
1. Sudden onset/offset of Palpitations
2. Chest pain
3. Dyspnea (SOB)
4. Syncope or Presyncope (dizziness / lightheadedness)

Signs
1. Tachycardia or Bradycardia
- Patient is aware of heart rate change in rate/rhythm
2. Hypotension / Low BP
3. Reduced oxygen saturation (below 90%)
4. Pallor, sweaty, clammy
5. Signs of heart failure

Presyncope 1. Dizziness and lightheadedness with no loss of consciousness

2. Muscle weakness
3. Blurred vision
4. Mild disorientation
5. Change in body temperatures
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6. Nausea / Vomiting

Syncope - Loss of consciousness resulting in some injury

- Rapid onset of collapse
- Short collapse duration
- Inability to maintain postural tone
- Spontaneous complete recovery

Symptoms of -
7. Palpitations
8. Chest pain
9. Aura (seizure-like)
10. Clammy and Pale

Cardiac Tamponade Beck’s Triad (elevated JVP, hypotension, muffled (reduced) heart
sounds, pulseless electrical activity)

Infective Endocarditis 1. Patient has a known valvular lesion - prosthetic, stenosis etc. 1. 3 sets of blood cultures
2. New murmur or changed murmur - indicating vegetation 2. Echocardiography (especially TOE)
3. Fevers, rigors, night sweats
4. Immunological phenomena
- Osler's nodes (painful red lesions on hand/feet)
- Janeway lesions (painless)
- Roth spots (retinal haemorrhage)
5. Embolic phenomena
- Splinter hemorrhages
- Arterial emboli (white, ischaemic legs)
- Pulmonary infarcts in IVDU (right-sided)

Myocarditis - Similar to ACS Diagnosis

1. Elevated inflammatory markers - ESR, fever, weight loss - ECG and clinical exam
2. Arrhythmia symptoms - onset/offset of Palpitations
3. Acute onset of chest pain - at rest or exercise Treatment
4. Elevated biomarkers (Troponin) - Manage sequelae of heart failure and
5. Non-specific ECG changes (i.e. Arrhythmias) arrhythmias
6. Delayed onset of heart failure or sudden cardiac death - Avoid NSAIDs, Alcohol, Exercise
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Cardiac Device 1. Recent surgical patient - if untreated, can cause BSI and Diagnosis
Infections Endocarditis Excision of device for culture
2. Localised area of red cellulitis near device
3. Pus discharge Treatment
4. Pain SSI Prevention Bundle - (APP) - Aseptic technique, prophylactic
antibiotics, post-operative wound care

Vascular Infections - Post-operative patients Treatment

- Infections of grafts placed in blood vessels Infection cannot clear from graft - Immunosuppression required
- AAA graft patient presenting with high fever for life

Prevention
SSI Prevention bundle (APP)

General Symptoms of
Heart Failure
● Fluid overload - Dyspnea, orthopnea, PND, weight gain 1. Transthoracic Echocardiogram
● Fatigued + reduced exercise tolerance 2. BNP or pro NT BNP ( > 500)
3. Coronary Angiography - indicated for CAD, Angina
4. X-Ray (upper lobe diversion, batwing features, and
dilated/hypertrophied heart)

Left Ventricular 1. Bibasal Crepitations

Failure (signs of high 2. Additional heart sounds - S3 Gallop, S4, Murmurs
filling pressures / 3. Displaced apex beat
overload) 4. Pulmonary oedema
5. Organ failure i.e. renal, hepatic, encephalopathy (reduced oxygen
saturation levels, cardiogenic shock)
6. Cough ± white/frothy or bloodstained sputum

Right Ventricular 1. Peripheral oedema (ankle swellings) - bilateral lower limb pitting
Failure (signs of high oedema, causing skin indentation - or sacral oedema
filling pressures / 2. Pleural effusions
overload) 3. Ascites
4. Hepatosplenomegaly / Pulsatile tender liver (elevated LFTs)
5. Distended neck veins - elevated JVP
6. Responsive to Hepatojugular reflux - (pressure on abdomen
causes an increase in JVP)
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7. Parasternal heave

Rheumatic Fever 1. Young child with flu-like symptoms, i.e. fever / ESR / weight
(BITES THE HEART, loss / ASOT
LICKS THE JOINTS) 2. Heart - PANCARDITIS
3. Joints - migrating arthralgia of large joints
4. Brain - Sydehman’s Chorea (inability to sit still, repetitive
movements)

Aortic Stenosis 1. Young, SAD male on exertion

(commonest) - Syncope on exertion
- Angina on exertion
- Dyspnea on exertion, reduced tolerance to exercise
2. Slow-rising (low-volume) pulse
3. Heart sounds - S2 soft, Split S2, S4
4. Displaced apex beat
5. Palpable systolic thrill
6. Systolic Murmur -
- Ejection systolic murmur (ejection click)
- Presents in the right-upper sternal border (base of
heart - right second ICS)
- Loudest in expiration and leaning forward
- Radiated to Carotids and apex (rumbling-like
sound)

Mitral regurgitation 1. Symptoms of LVF - dyspnea, orthopnea, PND

(second commonest) 2. Symptoms of atrial fibrillation (arrhythmia) - Palpitations
3. Mid to late Pansystolic murmur with a midsystolic click (Mitral
Valve Prolapse)
- Murmur Radiates to the axillae
4. Heart sounds - Soft S1, Split S2, S3 gallop

Aortic Regurgitation 1. Atypical chest pain

2. Palpitations
3. Wide pulse pressure
4. Corrigan’s (water-hammer) pulse - rising / falling
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arterial pulse
5. Heart sounds - Soft S1, variable S2, S3
6. Inferior and lateral displacement of apex beat
7. Diastolic murmur
- Blowing, high pitched, decrescendo diastolic
murmur
- Heard at the left sternal border, 3rd ICS
- Loudest in expiration and leaning forward
- Decreased with Valsalva maneuver

Mitral Stenosis 1. Symptoms of RVF - elevated JVP

2. Exertional dyspnoea + reduced tolerance to exercise
3. Chest pain
4. Fatigue
5. Haemoptysis
6. Low-volume pulse
7. Low-pitched rumbling Diastolic murmur at the
apex
8. Opening-snap sounds at S1
9. Malar flush (Mitral facies) - central cheeks and nose
is red, rest of face is blue/cyanotic

Abdominal Aortic 1. Peripheral embolisation - blue toe syndrome, skin rash
Aneurysm 2. Abdominal pain, flank pain, back pain
3. Rupture - hypovolemic shock with sudden epigastric or back pain
4. Fistulation (aorto-caval or aorto-enteric)
Rupture - Hypotension, pulsatile palpable mass, and flank pain
1. Ultrasound - GOLD STANDARD (determines size and
rupture risk)
2. CT Angiography - determines stenting or open repair
surgery is required, and presence of Tortuosity
(involvement of renal arteries to cause leaking)

Non-cardiac chest pain

Non-radiating pleuritic chest pain - worse with movement and inspiration Pulmonary embolism (PE)
Hypotensive with a systolic BP less than 90mmHg

Mid or lower abdominal pain due to acid reflux Peptic Ulcer / GORD
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Sharp, sudden onset of stabbing chest pain Pneumothorax

Localised with one finger
Classical in tall, young males that exercise

Chest discomfort due to bone palpitation and movement Costochondritis

Pain upon inspiration Pneumonia